Lincoln Villa

On 09/28/2021 at approximately 9:30am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced for another matter. LPA met with Administrator Divine Fernandez and explained the purpose of the visit. During visit LPA interviewed Administrator, two staff, and three residents. LPA reviewed staff roster, staff schedule, resident roster, physician reports, and activity schedule. One staff confirmed that facility does not always follow activity schedule. The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Continue from LIC9099... Interviews with S1 and ADM revealed that R2 went into R1’s room to get items such as food and a cup. According to Medroom Daily Communication Log dated 03/22/2025, R1 went to the front desk and told staff that R2 went to R1’s room, grabbed R1’s cup, and R2 hit R1 on the left side of the face. When staff interviewed R2 about the incident, R2 stated that they wanted the cup from R1’s room. The log also stated that when police arrived, resident refused to go to the hospital. LPAs interviewed R1 and stated that R2 hit R1 in R1’s room. R1 stated that R2 took R1’s food and hit R1’s left side of the head with R2’s hand. Then, R1 proceeded to go to the Med Room area to tell S1 what had happened. However, when R2 was interviewed, R2 does not recall going into R1’s room or that the incident occurred on 03/22/2025. After the incident, staff assessed R1 for injuries. Staff did not observe any bruising or swelling. R1 was monitored from 03/22/2025 to 03/25/2025 and still did not find any bruising or swelling. A review of R2’s medical assessment indicates R2 is ambulatory. There is no record observed that shows R2 having aggressive behavior. Staff interviewed denied witnessing R2 being aggressive to staff or any other resident. A copy of the police report was obtained. Police investigation did not indicate any injuries that occurred during the incident, but that staff will keep the residents separated. Based on record reviews and interviews conducted, the above allegation is unsubstantiated. Although the allegation, may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. There is no deficiency noted. Exit interview conducted and a copy of this report provided.

Continue from LIC9099.. Interview with R1 indicated that staff took R1’s hygiene products from their room that includes prescription items. Interviews with R2, R3, and R4 revealed that staff took belongings such as medications and supplies to place in a locked cabinet in their rooms. R1 confirmed that they received an item back, but not their prescribed item. Interview with Administrator (ADM) on 06/04/2025 revealed there is a facility policy to have a written physician’s order that explains that residents are allowed to have medications stored their room. A review of the facility policy on Medication Storage and Bedside Authorization on 06/04/2025 stated that residents can keep medications at their bedside if there is a written physician’s order that states that the residents need to for their care. However, a review of R1’s physician’s report dated 03/25/2025 showed that R1 is able to store prescription and PRN medications. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with Administrator. A copy of this report and appeal rights provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continue from LIC9099-A... During the initial visit on 04/23/2025, LPA toured the facility and did not observe any residents smelling of urine or in soiled undergarments. Interview with R1 stated that staff would not change their diapers and leave them soaked. 2 out of the 4 residents revealed that staff would assist them in diaper changes when needed and on their scheduled times. 1 out of the 4 residents interviewed can toilet on their own and stated that they do not need assistance with diaper change. Staff interviews revealed that they would check on the residents during their first round of the shift, every 2 hours after that, and as needed. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation are unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator.

On 06/06/2025 at 9:15 AM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that occured on 05/31/2025. Administrator self-reported the incident on 06/01/2025. LPA met with Administrator (ADM), Divine Fernandez, and explained the purpose of the visit. LPA received an incident report from the facility that indicated Resident 1 (R1) went AWOL. The facility staff was informed by R1's sister that the resident was seen outside of the facility. R1 was found by the police and escorted to the hospital for post fall. R1 returned to the facility later on that day. During the visit, LPA reviewed R1's Physician's Report dated 08/19/2024 that showed that R1 has a diagnosis of dementia and is unable to leave the facility unassisted. Interviews with ADM and Staff 1 (S1) indicated that residents with dementia has two bracelets such as a GPS tracker and one that will alarm when a resident is in close proximity of the exit doors. The GPS tracker revealed that R1 was still at the facility during that time. However, staff discovered later on that R1 took their GPS tracker off and placed it in the dining hall. S1 stated that they contacted 911 to follow their facility protocol for elopement when they were unable to locate R1. LPA attempted to interview R1, however, R1 does not recall the incident. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 03/20/2025 at 1:13 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen while at the facility for a pre-licensing observed the following deficiencies: At 10:50 AM, LPA observed the Med cart unlocked, and medications were found in Room #3, Room #15, and room #31. At 12:00 PM, LPA observed Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15. Deficiency is cited from Title 22 California Code of Regulation (see 809D). Failure to submit proof of correction and any repeat violation within twelve-month period may result in additional civil penalties. Exit interview conducted. Appeal Rights, and copy of this report provided via e-mail.

LIC9099-C (Page 2) Allegation: Licensee did not provide resident of monthly fees upon admission. Finding: Substantiated On 02/12/2025 LPA interviewed W (W1). W1 stated that Resident (R) R1 never received any documents on the payments and due dates. W1 stated that R1 became aware of unpaid payments in mid Oct/Nov '24. LPA interviewed Staff (S). S1 and S2 stated that billing invoices were mailed monthly to R1's home address on file and that they also hand delivered a copy to R1 at the facility. S1 and S2 stated that the mailed billing statements were being returned back undelivered. LPA interviewed R1 that stated that they never received any billing statements while at the facility. R1 stated that they do not remember receiving billing invoices and that they have not received anything monthly directly from the facility. R1 stated that the address on file is where they lived 2 years ago and that their family does not live at that address anymore. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted with Divine Fernandez. Appeal rights and copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC9099-C (Page 2) Allegation: Licensee did not obtain signature of resident’s representative on admission agreement. Finding: Unsubstantiated On 02/12/2025 LPA interviewed W (W1). W1 stated that Resident (R1) does not have an Responsible Party and that R1 is his own self responsible party financially. LPA interviewed R1 and R1 stated that they are the only person that signed the admission agreement. LPA reviewed R1's admission agreement documents and all documents obtained included R1's signatures. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 05/07/2025 at 3:35 PM, Licensing Program Analyst (LPA) P.Manalo arrived to do a Case Management visit. LPA met with the Administrator, Divina Fernandez, and explained the purpose of the visit. While at the facility for a pre-licensing, LPA observed the following deficiencies: At 1:30 PM, LPA observed TUMS unlocked in a drawer in room #43. At 3:00 PM, LPA observed Lysol wipes in the front office unlocked and accessible to residents. Deficiencies is cited from Title 22 California Code of Regulation (see 809D). Failure to submit proof of corrections and any repeat violation within twelve-month period may result in additional civil penalties. Exit interview conducted. Appeal Rights, and copy of this report.

LPA observed the lunch service at the facility where trays of food were being prepared for room service. S1 stated that each caregiver has a list of the residents getting tray service. The RP is on permanent tray service as she does not like to eat in the dining room and this incident was the only time she missed her tray service. Staff are mistreating a resident while in care: RP reported that she did not like one of the caregivers assigned to her and requested a change. She is currently happy with the caregiver. This agency has investigated the allegation that staff did not provide adequate meal service to a resident and staff are mistreating a resident while in care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

Staff does not ensure resident's room is kept clean: S1 stated that the facility has a housekeeper on the day and PM shifts and that rooms are cleaned once to twice a week and as needed. LPA observed all the residents’ rooms to be clean and free of any odors. The staff schedule also included the housekeeping staff. Staff does not ensure facility is properly sanitized: S1 stated the facility gets a deep cleaning (carpets cleaned and furniture sanitized) every 3 – 4 months. The most recent deep cleaning was on 1/14 and 1/15, 2024 This agency has investigated the allegation that staff does not ensure resident's hygiene needs are being met, staff does not ensure resident's room is kept clean and staff does not ensure facility is properly sanitized. staff did not provide adequate meal service to a resident. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

Resident suffered from dehydration while in care. It was noted on one of the home health visit that R1 had dark amber colored urine and home health nurse instructed on adequate fluid intake for R1. However, from the documents reviewed, there was no incident where R1 suffered dehydration. Interview with staff revealed that R1 did not like facility water and prefers sparkling water. R1's family bought sparkling water to the facility for R1. Resident's care needs were not being met. Interview with residents revealed that staff assist residents with ADL (Activities of Daily Living) care. Residents stated that their needs were met. After reviewing facility care notes, LPA observed that R1 sometimes refused ADL care. Interview with W2 revealed that R1 was clean when W2 visited and did not observed R1's hygiene needs not met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.

Continue from Lic9099 Based on interviews conducted, it was alleged that, staff do not ensure meals are made available to resident. LPA confirmed with five (5) staff members and all 5 staff members stated that meals are given to all residents, and room service is also available for residents if residents want to eat in their rooms. LPA confirmed with staff that other food options are given to residents if a resident does not like what is on the food menu for that day. R1, R2, R3, and R4 stated plenty of food is given to residents along with liquids. LPA obtained a food menu for January thought March 2023. Based on interviews conducted, it was alleged that, staff did not provide adequate care and supervision resulting in residents losing weight. LPA confirmed with five (5) staff members, and all 5 staff members stated that residents’ vitals are monitored and checked. A communication is filled out and submitted to the nurse to advise residents’ doctor. Residents PCP, doctors, nurses, and residents’ representative are notified regarding weight loss. Based on interviews conducted, it was alleged that, Staff prevented resident from having visitors. LPA confirmed with five (5) staff members, and all 5 staff members stated that visits are allowed to visit residents. LPA obtained a visitors log from December 2022- February 2023. R1-R4 stated that visits are allowed, and staff allows visitors to come and visit the residents at any time. All visitors have to sign in and out before entering the facility and leaving the facility. Based on interview conducted, Staff prevented resident from using assistive devices. LPA confirmed with five (5) staff members and all 5 staff members stated that residents’ use their assistive device when residents need to. S2 stated to LPA that staff will assist resident sometimes when a resident is walking around the facility with their assistive device. LPA observed residents walking around the facility with assistive devices during visit on 3/17/2023. Based on Interviews, and record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted with ADM, and a copy of this report provided.

On this day at around 9:57 am, Licensing Program Analyst arrived unannounced to deliver amended copy of the report previously issued on 11/9/2023. LPA met with Marissa Tangonan. LPA explained to Tangonan the purpose of the visit. LPA provided Tangonan a copy of the report.

Licensing Program Analyst (LPA) Delmundo conducted a case management inspection to ensure the facility is in compliance with applicable statutes and regulations and ensure the health and safety of residents. LPA met with Divina Fernandez, administrator (ADM), and informed the reason for visit. LPA conducted a tour of the physical plant with the ADM. Food supplies were checked and observed good for 2 days of perishables and 7 days of non-perishables. During the visit, the LPA conducted interviews with residents, staff and the administrator. Licensees are not on-site and not available for interview. LPA reviewed staff and resident files and checked the medication room. LPA observed the following: -at 2:45 pm, garden shears and rake in a broken storage in the courtyard. -at 2:52 pm to 3:15 pm, peritoneal cleanser, shaving cream in the residents rooms. -at 3:05 pm, unlocked housekeeping room where cleaning supplies are kept. -strong smell of urine in the hallway and activity area. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with ADM. An exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and a copy of the report provided.

On 6/9/2022 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator, Divina Fernandez. While LPA was at the facility for another visit, LPA observed the following deficiency: At around 2:20PM, LPA observed a staff left medication unattended while residents were walking around. A staff was preparing medications right outside the medication room and left the medication when LPA arrived at the facility. Staff did not lock up medication prior to helping LPA and visitor. LPA observed two residents passing by the unlocked tray of medication when staff was assisting LPA and visitor. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

Allegation: Facility not maintained clean and sanitary Investigation Finding: Substantiated During visit, LPA along with ED toured the facility including but not limited to residents' bedrooms, bathrooms, kitchen area, dining and living room areas. LPA inspected residents' bedrooms and bathrooms Rms# 30, 32, 33, 46, 36. LPA observed fecal matter on resident's bath chair in Rm# 36, bathroom floors in Rms 31 & 46 (Jack & Jill bathroom) were observed with urine and fecal stains. The preponderance of evidence has been met. Thus, this allegation is subtantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Staff forces residents to take medication Investigation Finding: Unsubstantiated During visit, LPA interviewed 3 residents (R2, R3, R4). Residents confirmed they receive their medications 3 or 4 times a day directly from the Med Techs. R2 stated to LPA that she has medications prescribed by her doctor that needs to be crushed. She stated she takes the crushed medications with apple sauce because they taste bitter. Residents stated Med Techs or caregivers do not camouflage their medications. Residents interviewed confirmed with LPA that they are not forced to take their medications by Med Techs or caregivers. They stated they take their medications from the cup given by the Med Tech on a daily basis. Med Tech (MT) told LPA that they directly administer the medications to the residents and keep an initialled medication administration record (MARs) on file for each residents' medication dosages and schedules for intake. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report provided.

On 4/20/2022 at 3:25PM Licensing Program Analyst (LPA) L. Hall and L. Holmes arrived unannounced to conduct a Case Management. LPA met with Davina Fernandez, Administrator. When LPA L. Hall delivered complaint findings (15-AS-20201002150036) on 4/20/2022, LPA reviewed R2's file and observed facility did not request an exemption before admitting a resident with a restricted health condition. S1 stated that the facility did not request an exemption. The following deficiency was observed: - On 4/20/2022 LPA reviewed R2's file and did not observed an exemption for a restricted health condition. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.